VENTILATORS

5.1 Mechanics Of Respiration

Every pulmonary cycle consists of the following phases: intake of breath (inspiration) and
exhalation (expiration).

When we inhale, the intercostal muscles (between the ribs) and diaphragm contract to expand
the chest cavity. The diaphragm flattens and moves downwards and the intercostal muscles
move the rib cage upwards and out. This increase in size decreases the internal air pressure and
so air from the outside (at a now higher pressure that inside the thorax) rushes into the lungs to
equalise the pressures. When we exhale the diaphragm and intercostal muscles relax and return
to their resting positions. This reduces the size of the thoracic cavity, thereby increasing the
pressure and forcing air out of the lungs.

Only at the optimal course of pulmonary cycles, a sufficient extraction of CO2 from the blood
and its saturation by oxygen are provided.

There are two ways how the lungs can be shrunk or stretched:

The activity of the diaphragm

5.2 Artificial Ventilation

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For reduced breathing or respiratory failures, mechanical devices are used. These devices
supply enough oxygen and eliminate the right amount of CO2 and maintain the desired arterial
partial pressure of O2 and CO2. The aids are mask, breathing valves and self filling bags. The
masks are held firmly over the patients mouth and nose. The breathing valve guides the air to
the patient and removes the unwanted air. The bag acts as a pump and is squeezed by hand.

5.3 Ventilators

These are used when artificial ventilation is to be used for a long time. The main function is to
ventilate the lungs close to the natural process.
Negative pressure ventilators generate a negative pressure inside the lungs or around the

thoracic volume and dropping the pressure inside the lungs, giving a pressure gradient between
the atmosphere and lungs which causes the flow of air into the lungs. These are not commonly
used.

Positive pressure ventilators generate inspiratory flow by applying a positive pressure. They
operate in mandatory or spontaneous mode.

5.4 Types Of Ventilators

Anaesthesia ventilators- Small and simple equipments used to assist during operations.
Intensive care ventilators- They are complicated and are used over a range of parameters.
They incorporate patient triggering facility.

5.5 Ventilator Terms

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IMV (intermittent mandatory ventilation) :

A breath sequence in which spontaneous breaths are permitted between mandatory breaths.

Tidal volume

The volume of gas/air delivered with each breath.

Inspiratory and expiratory times

The total time required for one complete respiratory cycle. Typically, patients are comfortable
with an expiratory time two to three times longer than the inspiratory time.

Inspiratory reserve volume IRV

This term means the maximal volume of air that can be inhaled after completion of resting
inspiration. 3000ml

Expiratory reserve volume ERV

It is the maximal volume of air which can be exhaled after the completion of the resting
expiration. 1100ml

Residual volume RV

Residual volume is the volume of air that remains in the lungs after a maximum forced
expiration, thus the amount of air remaining in the maximally contracted lungs. For an adult
70 kg man is about 1200 ml.

Functional residual capacity FRC

Functional residual capacity is the amount of air that remains in the lungs after completed
resting exhalation and is equal to the sum of expiratory reserve volume and residual volume of
the lungs.

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FRC = ERV + RV

For an adult 70 kg man is thus about 2300 ml.

Vital capacity VC
The maximal volume of air that can be exhaled after the completion of the maximal forced
inspiration. In other words, it is the volume of air that the lungs are able to expel by maximum
exhalation after maximal strenuous inspiration. It therefore represents a sum of inspiratory
reserve volume, tidal volume and expiratory reserve volume.

VC = IRV + VT + ERV

For an adult 70 kg man comprises about 4600 ml.

Total lung capacity TLC

Total lung capacity is the maximal volume of air that can be held in the lungs after maximal
forced inspiration. It can also be said that this is the maximal volume w
lungs achieve. It is the sum of all four volumes described above, i.e. residual volume,
expiratory reserve, tidal and inspiratory reserve volume. More often is expressed as the sum of
vital capacity and residual volume of the lungs.

TLC = RV + ERV + VT + IRV = VC + RV

For an adult 70 kg man this value reaches about 5800 ml.

Lung compliance
A measure of the ease of expansion of the lungs and thorax, determined by pulmonary volume
and elasticity.

Minute Volume

Respiratory minute volume is the volume of gas inhaled (inhaled minute volume) or exhaled
(exhaled minute volume) from a person's lungs per minute.

Airway resistance

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The ease with which air flows through the respiratory passage.

Respiration rate
The number of breaths per minute.

Synchronized Intermittent-Mandatory Ventilation (SIMV)

A combination of machine ventilation and spontaneous breathing.

Peak airway pressure

Peak inspiratory pressure (PIP) is the highest level of pressure applied to the lungs during
inhalation

5.6 Classification Of Ventilators

Based on the method of initiating the inspiratory phase

Controller

Assistor
inspiratory
effort.

Assistor/Controller
It combines both the assistor and controller functions.

Based on power transmission

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Direct power transmission
Delivers gas directly from the source to the patient.

Indirect power transmission

It separates the patient and power systems.

Based on Pressure pattern

Positive atmosphere

spontaneously.

Positive Negative
It produces a positive pressure in t
lowers during the expiratory phase.

Positive-Positive

pressure greater than atmospheric pressure.

Based on the type of safety limit

Volume limited
The ventilator in which the pre determined volume cannot be exceeded during inspiration

Pressure limited
The ventilator in which the pre determined pressure cannot be exceeded during inspiration.

Time limited
The ventilator in which the pre dtermined phase timee cannot be exceeded during inspiration.

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Based on source of power

Pneumatic
Powered by compressed gas

Electric
Powered by electrical device like motors

Based on cycling control

The cycling control determines the change from inspiratory phase to expiratory phase and vice
versa.

5.7 Pressure Volume Flow Diagrams

Pressure-time, flow-time and volume-time diagrams are needed to understand the performance
of ventilators.

The ventilated system comprises the patient circuit, airways and the alveoli having its own
compliance.

At the start of the inspiratory phase, a gas volume is given to the system which results in an
pressure in the patient circuit and a flow through the airway. During this phase, the airway
pressure and alveolar pressure increase gradually with airway pressure greater than alveolar
pressure. The equal pressure of patient circuit and alveoli informs the end of the inspiratory
phase and beginning of the expiratory volume.

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The expiratory flow is the difference between alveolar pressure and pressure in the patient
circuit. A pause time or time delay should be provided between the cycling of the ventilator
and the change from inspiratory to expiratory flow.

5.8 Modern Ventilators

A ventilator is an electromechanical (or, possibly, completely mechanical) device designed to

provide all or part of the effort required to move gas into and out of a person's lungs.

It has two interconnected systems Pneumatic flow system and electronic control system.

Pneumatic flow system

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This device ensures proper level of O2 in inspiratory air.

O2 and medical grade air enters into the ventilator at 3.5 bar pressure through built in 0.1 micro
filter. These gases enter the mixer and the 8 liters reservoir.

An electronically entered flow value proportions the gas flow from reservoir tank to patient
breathing circuit. As the gases leave the ventilator, they pass by an O2 analyser, a safety
ambient air inlet valve and back up mechanical pressure valve. The ambient valve provides the
patient the ability to breathe room air when the machine fails or pressure in patient circuit
decreases.

A bi directional flow sensor in the breathing circuit measured the gas flow. The exhaled gases
flow through the electronically controlled exhalation valve.
The microprocessor controls each valve to deliver the desired inspiratory air and O2 for
spontaneous and mandatory ventilation.

Electronic Control System

It uses one or more microprocessors and software to perform monitoring and control functions.

The parameters include setting of respiration rate, flow waveform, tidal volume, peak flow and
PEEP. The PEEP controls the exhalation flow.

These parameters are used to compute desired inspiratory flow. The system consists of monitors
for pressure flow and O2 flow sensors. These are connected to electronic processing circuits and
values are displayed. The pressure sensors are strain gauges. Fuel cell type sensors are used to
measure fraction of O2. Thermistors are used to measure temperature.
Ventilators need regular maintenance and calibration.

5.9 High Frequency Ventilators

High frequency ventilation is a type of mechanical ventilation which utilizes a respiratory rate

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 greater than 4 times the normal value.

High frequency ventilation reduces ventilator-associated lung injury (VALI), especially in the
context of ARDS and acute lung injury. This is commonly referred to as lung protective
ventilation.
High frequency ventilation may be used alone, or in combination with conventional mechanical
ventilation.

There are three distinguishing characteristics of high-frequency oscillatory ventilation: the

frequency range from 5 to 50 Hz (300 to 3000 bpm); active inspiration and active expiration;
tidal volumes about the size of the dead space volume.

There are four basic types of HFV: high frequency jet ventilation, high frequency oscillatory
ventilation, high frequency percussive ventilation, and high frequency positive pressure
ventilation. Among these, high frequency oscillatory ventilation is the mode that is used most
often.

HFV provides adequate alveolar ventilation and oxygenation without high inspiratory pressure.

Babylog 8000 uses oscillating diaphragm mechanism which is computer controlled. It

determines the shape of pressure swings and I: E ratio.

5.10 Humidifiers, Nebulisers and Aspirators

Humidifiers replace humidity in the upper air passages which has been lost due to intubation.
It should be close to 100%. It prevents damage to the lungs and air passages. It is done by heat
vapourization or bubbling air through a jar of water.

Nebulizers are used when any medication has to be administered as an aerosol. The water or
medication is picked by high velocity jet of oxygen which causes droplets to be formed which
are then given to the patient. Ultrasound nebulisers are also used.

Aspirators are used along with ventilators to remove mucus and other fluids from the airways.
Suction devices are also used.

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